Pharm Quiz 4 Hard

Oral Diabetic Agents

Biguanides

• Metformin (Glucophage XR, Riomet, Fortamet, Glycon) is an example of this drug class.
• Decreases hepatic glucose production (hepatic gluconeogenesis).
• Increases peripheral utilization of glucose by increasing tissue sensitivity to insulin.
• Decreases intestinal glucose production.
• Improves glucose uptake in muscles.
• Does not increase insulin secretion from the pancreas.
• Not associated with hypoglycemia.
• Used as a first-line therapy for type 2 diabetes, especially in overweight patients.
• Modulates the rise in glucose that happens after a meal.
• Should not be used in patients with renal impairment, severe heart failure, metabolic acidosis, liver disease, MI, or septicemia.
• Should not be used with contrast agents.
• Can cause GI upset (nausea, diarrhea, vomiting, abdominal pain, flatulence, anorexia)
• Can cause lactic acidosis (rare but serious: BLACK BOX warning).
• Increases risk of Hepatic failure, cardiac failure, renal failure, Vitamin B12 deficiency.
• Hold 48 hours before and after contrast studies.
• Monitor renal function (eGFR).
• Check LFTs and creatinine.
• Discontinue if creatinine > 1.5 mg/dl in men or 1.4 mg/dl in women.
• Ensure levels are normal before initiating therapy.
• Educate patients to take with food to reduce GI side effects.
• Monitor Vitamin B12 levels every 2-3 years.

Sulfonylureas

• First Generation Drugs: Acetohexamide (Dymelor), Chlorpropamide (Diabinese), Tolazamide (Tolinase), Tolbutamide (Orinase)
• Second Generation: Glyburide (Diabeta, Glynase Prestabs, Micronase); Diabeta, Daonil
• Mechanism of Action: inhibiting the potassium channel in the pancreatic beta cell, thus resulting in depolarization and activation of calcium channels which result in enhanced insulin secretion
• Indications; Type 2 diabetes (when metformin insufficient); 2nd generation more potent, but no therapeutic difference between 1st and 2nd generation; 2nd generation have fewer adverse reactions; actively drive blood glucose down by increasing insulin
• Contraindications: Type 1 diabetes; Sulfa allergy; Severe renal/liver disease
• Adverse Effects: Hypoglycemia, weight gain, photosensitivity, GI effects: nausea, epigastric fullness, heartburn; Skin reactions: pruritic, erythema, urticaria and maculopapular eruptions (transient, disappear with cont. therapy); Hepatotoxicity
• Nursing: Administer 30 minutes before meals; Educate on hypoglycemia signs (shakiness, confusion); Caution in elderly patients due to risk of hypoglycemia.

Meglitinides

• Repaglinide (Prandin); Gluconorm; Nateglinide (Starlix)
• Stimulates rapid, short-lived insulin secretion from the pancreas by interacting with binding sites on the potassium channel in the pancreatic beta cell membrane.
• Type 2 diabetes (especially for postprandial spikes).
• Helpful in treating patients that have meal-related hyperglycemia who haven't responded to other agents.
• Actively drive blood glucose down by increasing insulin release from beta cells of the pancreas.
• Contraindications: Type 1 diabetes, severe liver disease.
• Adverse Effects: Hypoglycemia, weight gain.
• Nursing: Take 30 minutes before meals; skip dose if skipping a meal; monitor for hypoglycemia, especially with erratic eating habits.

Thiazolidinediones (TZDs)

• Rosiglitazone (Avandia); Pioglitazone (Actos)
• Effective only in the presence of insulin
• Decreases insulin resistance at peripheral sites and in the liver resulting in increased insulin-dependent glucose disposal.
• Indications: Type 2 diabetes (may be used as monotherapy or in combination with other oral agents).
• Can be used in patients with renal dysfunction.
• Contraindications: Heart failure (NYHA Class III/IV), bladder cancer, liver disease.
• Adverse Effects: Fluid retention (peripheral edema), Hypoglycemia, risk of bladder CA with pioglitazone (Actos), weight gain, heart failure, increased fracture risk.
• Nursing: Monitor for signs of heart failure (edema, dyspnea), assess liver enzymes regularly, educate about possible weight gain and fluid retention.

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

• Sitagliptin (Januvia); Linagliptin (Tradjenta); Saxagliptin (Onglyza)
• Inhibit DPP-4 enzyme, prolonging incretin hormone activity to increase insulin release and decrease glucagon secretion.
• Indications: Type 2 diabetes; use in mono or combo therapy for DM; use as adjunct to diet and exercise to improve glycemic control in Type 2 DM.
• History of pancreatitis, Severe renal disease.
• Adverse Effects: Pancreatitis, upper respiratory infections, joint pain, nasopharyngitis, headaches, hypersensitivity reaction.
• Monitor for pancreatitis symptoms (severe abdominal pain), assess renal function before starting therapy.

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

• Empagliflozin (Jardiance); Canagliflozin (Invokana); Dapagliflozin (Farxiga)
• ↑ glucose excretion via the urine by inhibiting SGLT-2 in the kidney tubules, ↓ glucose levels and inducing weight loss via caloric loss through the urine.
• Indications: Type 2 diabetes, cardiovascular risk reduction, chronic kidney disease.
• Severe renal impairment, recurrent UTIs, history of diabetic ketoacidosis.
• Adverse Effects: UTIs, female genital fungal infections, dehydration, hypotension, ketoacidosis, urosepsis, pyelonephritis, ↑ risk for amputation.
• Encourage hydration to prevent dehydration and UTIs, Monitor blood pressure and renal function, educate patients on genital hygiene to prevent infections.

Alpha-Glucosidase Inhibitors

• Acarbose (Precose); Miglitol (Glyset)
• Delay and decrease carbohydrate absorption in the GI tract by inhibiting the enzyme alpha-glucosidase.
• Delays glucose absorption.
• Lowers postprandial glucose levels.
• Indications: Type 2 diabetes (especially for postprandial glucose control); can be used as first-line drugs or adjunctive drugs in the treatment of Type 2 DM but generally used 2nd line due to frequency of admin; appropriate for individuals with normal FBS levels but increased postprandial readings (after dinner or lunch).
• Contraindications: Inflammatory bowel disease, intestinal obstruction, severe renal dysfunction.
• Adverse Effects: Flatulence, bloating, diarrhea, abdominal pain. Doses >100mg TID of acarbose cause an increase in serum transaminase levels in 15% of patients.
• Take with the first bite of a meal.
• Treat hypoglycemia with glucose (not sucrose) due to delayed sugar absorption.
• Treat hypoglycemia with glucose tablets or glucagon injection because sucrose-containing candy will not be absorbed.

Levothyroxine

• Synthetic form of thyroxine (T4) converted into triiodothyronine (T3) in the body.
• T3 is the active form that binds to thyroid hormone receptors, regulating gene expression and controlling processes like metabolism, growth and development.
• Indications: Primary hypothyroidism (Hashimoto's thyroiditis, iodine deficiency), Secondary hypothyroidism (pituitary or hypothalamic dysfunction), Myxedema coma (severe hypothyroidism), Goiter management, and Thyroid cancer (as suppressive therapy to prevent tumor recurrence).
• Contraindications: Untreated adrenal insufficiency, Acute MI, Thyrotoxicosis (untreated hyperthyroidism), Hypersensitivity to the drug or its components.
• Adverse Effects: Usually only seen when excessive doses, excessive iatrogenic hyperthyroidism, With an acute overdose, thyrotoxicosis may result. Signs and symptoms include tachycardia, angina, tremor, nervousness, insomnia, hyperthermia, heat intolerance, and sweating
• Monitor thyroid function tests (TSH, free T4) regularly, and assess for signs of hypo- or hyperthyroidism. Also, monitor heart rate and blood pressure, especially in older adults or those with cardiac disease
• Give on an empty stomach, ideally 30-60 minutes before breakfast, with a full glass of water
• Avoid giving with calcium, iron, or antacids (these interfere with absorption)
• Patient Education: Emphasize lifelong therapy and the need for regular follow-ups, signs of too little/much hormone
• Emergency Considerations: Recognize signs of myxedema coma or thyroid storm, IV levothyroxine may be necessary for severe cases like myxedema coma.

Antacids

• Mechanism of Action: Neutralize gastric acid by raising the pH of stomach contents, interacting with hydrochloric acid (HCl) to form water and various salts, reducing acidity and relieving symptoms.
• Indications: GERD, Peptic ulcer disease (PUD), Dyspepsia (indigestion), Heartburn, Hyperphosphatemia.
• Contraindications: Severe renal impairment, Hypercalcemia or nephrolithiasis, and Heart failure or hypertension.
• Adverse Effects: Diarrhea, hypermagnesemia, Constipation, hypophosphatemia, and metabolic alkalosis
• Assess GI symptoms Relief of heartburn, electrolyte and kidnely funtion
• Patient education on lifestyle & short term use.

Proton Pump Inhibitors

• Omeprazole (Prilosec); Esomeprazole (Nexium); Lansoprazole (Prevacid); Pantoprazole (Protonix); Rabeprazole (Aciphex); Dexlansoprazole (Dexilant)
• Mechanism of Action: PPIs irreversibly inhibit the H+/K+ ATPase pump in the gastric parietal cells, preventing the final step of gastric acid secretion. drastically reduces stomach acid production, lowering gastric acidity and promoting healing of the mucosa.
• Indications: GERD, Peptic ulcer disease (PUD), Erosive esophagitis, Zollinger-Ellison syndrome, H. pylori infection, Stress ulcer prophylaxis in critically ill patients.
• Contraindications: Hypersensitivity to PPIs, Severe liver disease, patients with Osteoporosis
• Common Adverse Effects: Headache, nausea, diarrhea, abdominal pain, Pneumonia
• Timing: Give 30-60 minutes before meals, usually in the morning, Do not crush, chew or swallow whole capsules

Misoprostol (Cytotec)

• Synthetic prostaglandin E1 (PGE1) analog
• Inhibits gastric acid secretion by binding to prostaglandin receptors on parietal cells
• Enhances bicarbonate and mucus secretion promoting gastric mucosal protection
• Indicated for prevention of NSAID-induced gastric ulcers, Cervical ripening, Management of miscarriage, and Postpartum hemorrhage
• Contraindications: Pregnancy and Hypersensitivity to prostaglandins
• Side Effects: Diarrhea, abdominal pain, nausea, flatulence, uterine cramping, and vaginal bleeding
• Administer with meals, explain process and effects

H. Pylori Treatment

Triple Therapy (1st Line Treatment)

• PPI (Proton pump inhibitor) to reduce stomach acid
• Clarithromycin (500mg BID)
• Amoxicillin 1gm BID or Metronidazole 500mg BID
• Treatment for 10-14 days

Quadruple Therapy (Alternative Treatment)

• PPI
• Bismuth subsalicylate 535mg QID
• Tetracycline 500mg QID
• Metronidazole 250mg QID
• Treatment is for 10-14 days

Sequential Therapy (Less Common)

• Standard dose PPI + amoxicillin 1 gm BID for 5 days
• Followed by PPI + clarithromycin 500mg once a day + tinidazole 500mg BID for 5-7 days
• Involves taking different combinations of antibiotics and a PPI over 10 days

Concomitant Therapy

• PPI and three antibiotics (clarithromycin, amoxicillin, and metronidazole)
• Taken simultaneously.

Levopdopa

• Commonly combined with Carbidopa, as in Sinemet
• Levodopa is a dopamine precursor that crosses the blood-brain barrier (BBB.
• Once in the brain, it is converted to dopamine by dopa decarboxylase, replenishing depleted dopamine in the basal ganglia
• Indications: Parkinson's disease, Parkinsonism, Restless leg syndrome (off-label)
• Contraindications: Narrow-angle glaucoma, Severe cardiovascular disease, Psychotic disorders.
• Watch for mood changes or hallucinations
• Give 30 minutes before meals

Acetylcholinesterase Inhibitor

• Donepezil (Aricept, Rivastigmine (Exelon), Galantamine (Razadyne)
• Inhibits the enzyme acetylcholinesterase, preventing the breakdown of acetylcholine in the brain.
• It boosts cholinergic neurotransmission, helping improve cognitive function in Alzheimer's disease

Phenytoin

• Used to treat seizures
• Stabilizes neuronal membranes by inhibiting voltage sodium channels, reducing neural activity
• Don't give during pregnancy
• Can cause gingival hyperplasia

Depakene

• Valproic acid, Used to treat and prevent seizures while stabilizing mood
• Can be used to treat bipolar disorder while treating dementia
• Can lead to hairloss and weight gain.

Overactive Bladder Medications

Anticholinergics (1st line medications)

• Oxybutynin, Tolterodine, Solifenacin, Darifenacin
• Blocks muscarinic receptors, reducing the bladder's involuntary contractions, increasing capacity of bladder
• Leads to dry mouth, nausea,,
• For Dry mouth - Hydration and oral car
• Fiber and stool softeners: For constipation

Oral Contraceptives

Combination Oral Contraceptives

• Drug Class*: Combination, Estrogen and Progestrin combo
• Inhibits Luteinizing and Follicle-Stimulating Hormone from releasing thus supressing ovulation
• Contraindications: thromboembolic events, severe hypertension, Breast cancer, liver disease
• Patient Education: Increases risk of pregnancy in missed period cases

Mini Pills

• Safe during breastfeeding but can cause hair loss.
• Contraindications: with hx of Breast cancer or severe liver problems
• Progestrin-Only

Viagra

• Sildenafil (Viagra, Revatio)
• Indications: Erectile Dysfunction (ED) and Pulmonary Arterial Hypertension (PAH). Off-label uses for Raynaud's phenomenon and altitude sickness.
• Inhibits PDE5, thus vasodialating increasing blood flow to the pennis
• Adverse Effects: Headache, flushing, dyspepsia, nasal congestion, dizziness, Visual disturbances.
• Use caution when pt had Low BP

Finasteride

• Indications: Benign Prostatic Hyperplasia (BPH) and Androgenic Alopecia (male pattern baldness).
• Adverse Effects: Sexual dysfunction, Gynecomastia, , ejaculatory problems
• Proscar, Propecia
• Pt with hairloss Has Pregnancy
• Pt may need a catheter

Laxatives

Bulk-Forming Laxatives

These absorbent, water increasing laxatives that are used to treat constipation diverticulosis Psyllium (Metamucil) • Ensure the patient drinks plenty of water to prevent esophageal or intestinal obstruction

Surfactant Laxatives (stool softeners)

lower the surface tension of stool to and are Used to prevent straining recovering birth ex. Docusate sodium

• Ensure they take with lots of water and arent used for quick relive

Stimulant Laxatives

• Used for short-term relief
• Stimulate the intestinal nerves and used as a bowel prep before procedures •Avoid prolonged use + hydrate

Osmotic Laxatives

• Used for bowel prep and draws lots of water lactulose and magnesium citrate •Ensure adequate hydration and monitor electrolites